Cradle Kalamazoo - Collective Impact in Action

CityMatCH Annual ConferencePortland, Oregon

September 14, 2018

Cradle Kalamazoo - Collective Impact in Action

Catherine L. Kothari PhD1, Grace Lubwama DPP2, Terra Bautista3, Deb Lenz3, Joia Creer Perry MD4, Carmen Green MPH4, Katie Corbit3, Lisa Graves MD1

1Western Michigan University Homer Stryker M.D. School of Medicine, 2YWCA of Kalamazoo 3Kalamazoo Health and Community Services, 4National Birth Equity Collaborative

Getting in the Door and Staying There Lisa Graves MD Associate Dean, WMed & Cradle Clinical lead

Kalamazoo CountyThree Year Moving Average Infant Mortality Rate, By Race

-1997 to 2017*-

9.8

13.214.0

20.819.5

20.9

18.016.016.8

16.819.219.5

18.317.615.5

14.215.3

11.013.0

7.0 6.5 7.28.6 8.5

6.45.4 4.6 5.0 4.8 5.5 5.7

4.8 3.9 3.9 4.7 4.73.2 3.6

1997

-199

9

1998

-200

0

1999

-200

1

2000

-200

2

2001

-200

3

2002

-200

4

2003

-200

5

2004

-200

6

2005

-200

7

2006

-200

8

2007

-200

9

2008

-201

0

2009

-201

1

2010

-201

2

2011

-201

3

2012

-201

4

2013

-201

5

2014

-201

6

2015

-201

7

blackwhite

Met Healthy People 2020

Goal of 6.0 IMR

*2014-2016 & 2015-2017 are estimated, not the official rates.

3.6 RR

COLLECTIVE IMPACT – The Goal

“Large-scale social change requires broad cross-sector coordination….”

Kania, J. & Kramer, M. (2011) Collective Impact. Stanford Social Innovation Review. Winter, 2011.

COLLECTIVE IMPACT – The Challenges

Kania, J. & Kramer, M. (2011) Collective Impact. Stanford Social Innovation Review. Winter, 2011.

“…yet [we] remain focused on the isolated

intervention of individual

organizations.”

COLLECTIVE IMPACT – The Parts

• COMMON AGENDA

• MUTUALLY REINFORCING ACTIVITIES

• SHARED MEASUREMENT

• CONTINUOUS COMMUNICATION

• BACKBONE SUPPORT

COLLECTIVE ACTION COLLECTIVE IMPACT

Clinical Social

• Complex issues require multidisciplinary strategies & interventions.

• No one solution or organization will be able to solve infant mortality by themselves.

• Cradle’s overall goal is to improve infant mortality, knowing that only 10-20% of health is impacted by clinical care.

10-20% 80-90%

• Build awareness

• Build Community Partners

• Identify the issue in the community

• Learn from the past

GETTING STARTED

PHASE 1: GENERATING IDEAS AND DIALOGUE: 2014

ACTIVITIES• One-on-one meetings with stakeholders

• Kickoff Conference (November, 2014)

• Media coverage

Equity Focus Data-Driven Collective

ImpactCommunity Engagement


PHASE 2: STRATEGIC PROCESS: 2015

ROOTED IN STRATEGY

• Identify priority areas

• Identify strategic partners

• Analyze baseline data and key issues

• Map the landscape and use data to make case

ACTIVITIES• Community Workshops (March & May,

2015)

• Fundraising

• Research Race X SES further

• Strategic Planning Consultant / Process

Funding:



CRADLE GOALS

• Cradle Kalamazoo: In the next 10 years, Cradle is organizing strategies to create zero disparities in infant mortality and an overall infant mortality rate of less of 3.0 per 1,000 lives births

Shared ProsperityK-12 & KzooPromise

Early Edu.Cradle Kzoo

0 5 yrs Puberty Pregnancy Life Course

Overall well-being of all children & families in Kalamazoo

ALIGNING STRATEGY WITH CAUSE

Problem Cause1. Fragmented Systems of care2. Stress from poverty & discrimination3. Lack of opportunity & access4. Health Literacy

Strategic Objectives1. Coordinating perinatal home visitation network,

2. Incorporating health equity into practices & policies,

3. Providing reproductive health education,

4. Providing safe sleep education.


PHASE 2: STRATEGIC PROCESS: 2014-15

PHASE 3: INITIAL ACTION: 2015-16

ORGANIZING

• Facilitate community outreach

• Identify funding• Establish

shared metrics

ACTIVITIES• Announced plan at annual meeting

• Workgroups to develop each objective

• Hired administrative backbone

• Public Health Marketing

• Fundraising

Funding:• Kalamazoo

CountyHealth Plan

• Michigan Health Endowment Fund




PHASE 2: STRATEGIC PROCESS: 2014-15

PHASE 3: INITIAL ACTION: 2015-16PHASE 4: ORGANIZE FOR IMPACT: 2016 - 2018

IMPLEMENTATION

• Create infrastructure and process

• Create common agenda, goals and strategy

• Continue to engage

ACTIVITIES• Baby Hotline

• Implement Data Hub

• Fundraising

• Continuum of care

Funding:



CRADLE ACHIEVEMENTS 2014-2018

• Administrative & Data Backbone raised $1.8 million (2014-2018) to support admin, data, and expanded programming

• Coordinated over 400 meetings with 30 community partners at 8 committees

• In 2017-2018, Hosted 22 community events with a total of 784 attendees and volunteers

Safe Sleep• Coordinated

education with home visitation

• Designed standardized education and messaging

Health Equity• Commitment for

IM from City & County Commissions

• Review of equity in initiative

• Funded community engagement & equity work within clinics

Home Visitation

• Built Care Coordination Registry with 7 perinatal HV programs

• Supported care coordination between programs with Frontline meetings

Reproductive Health

• Coordinated education with home visitation


CRADLE ACHIEVEMENTS 2014-2018

16

WHERE WE STARTED: Cradle’s first structure (2015)

Steering Committee

Data Backbone• Database/Care Coordination Registry• Mom’s Experience Survey• Cradle Kalamazoo Research

Administrative Backbone

• Oversee day-to-day• Marketing• Status of projects

Best Babies Zone

FIMR Community Engagement

/CHWs

Frontline Meetings

Health Equity Subcommittee

Fetal Infant Mortality Review

Home VisitationSubcommittee

Reproductive HealthSubcommittee

Safe SleepSubcommittee

IntentionalEquity FocusAwareness

CRADLE RE-STRUCTURE

Coordinating Across Agencies & ProgramsTerra Bautista (Healthy Babies Healthy Start Coord)

“Alone we can do so little…”

Cradle Hotline…. 2-1-1 Gryphon Place

20

https://www.youtube.com/watch?v=GBC5Gu8MQFU&t=1s

Cradle Hotline (888-KIDS) & 2-1-1 Screening

• 100+ calls into hotline• 10,000 2-1-1 callers

screened annually for pregnancy

• 61 women enrolled in home visitation program

https://www.youtube.com/watch?v=GBC5Gu8MQFU&t=1s

Safe Sleep• Coordinated

education with home visitation


Health Equity• Commitment for

IM from City & County Commissions

• Review of equity in initiative

• Funded community engagement & equity work within clinics

Home Visitation

• Built Care Coordination Registry with 6 perinatal HV programs

• Supported care coordination between programs with Frontline meetings

Reproductive Health

• Coordinated education with home visitation


CRADLE COORDINATION ACHIEVEMENTS

CRADLE Home Visitation Coordination

ClinicClinicClinicClinicClinic

23

CLINIC TO COMMUNITY COORDINATION

ClinicClinicClinicClinicClinic

COORDINATED CARE

“… together we can do so much”

9 data-sharing participants:• Seven home visiting programs• Two CHW programsMultiple community programs

• Early childhood home visiting• Service presentations

48 weekly meetings since 2017

254 Cases reviewed• Thirty-eight brain-storming• Two hundred-sixteen hand-offs

COORDINATED CARE STRATEGIES

1. Clinic to Community• Home Visitation (case managers, doulas, CHWs)• Planning for automatic, universal referral

2. SDOH Collaboration Platform, ASCENSION BORGESS TAV • Promote coordination between clinic & community

resources

3. Community to Clinic• Street outreach, resource linkage & re-engagement • Community education

4. Care Coordination Registry• Updated contact info for enrollment / retention• Referral portal for agencies, clinics, & community

SDOH COLLABORATION PLATFORM

Pilot an electronic care coordination platform

Bridging services

27

Community to clinic

Clinic to Community

Coordinated Care: CHW Strategy

Community to Clinic

YWCA

WMED KCHSD

CHW

Inter- AgencyProviders

StaffDepartments

Pregnancy Testing

OB/GYNCare Team

Medical Appointment

Time of Delivery

Clinic to Community

Community Events

Neighborhoods

Community Educational

Classes

Pregnancy Testing

Community Relationships

Community to Clinic

• Increased support for families• Wrap-Around Case Sharing

Awareness

Willingness

Access

Outreach increases community-engagement:

Taking Clinical Continuum-of-Care into Neighborhoods and Homes

Carmen Green MPH (National Birth Equity Collaborative, Cradle Health Equity Consultants)

Overview

• Capacity Building grant from MDHHS – Minority Health

• Goal to eliminate racial and ethnic health disparities through implementing culturally appropriate, evidence-based approaches

Overall Program & Evaluation

• Purpose of this grant is to support goal: ensuring health equity and cultural competency of programs, policies, and providers.

• Partnering with 3 clinical sites (Ascension Borgess, Bronson, Family Health Center) to improve cultural competency of clinical processes and procedures that impact maternal and infant health

MissionTo reduce Black maternal and infant mortality through research, family centered collaboration and advocacy.

GoalReducing black infant mortality rates by 50% in the next 10

years.

Our vision is that every Black infant will celebrate a healthy first birthday

with their families.

birth equity (noun):

1. The assurance of the conditions of optimal births for all people with a willingness to address racial and social inequalities in a sustained effort.

Joia Crear-Perry, MDNational Birth Equity Collaborative

Root Causes

Power and Wealth ImbalanceLABOR

MARKETS

GLOBALIZATION&

DEREGULATIONHOUSINGPOLICY

EDUCATIONSYSTEMS

TAXPOLICY

Social Determinants of Health

Disparity in the Distribution of Disease, Illness, and Wellbeing

InstitutionalRacism

Class Oppression Gender Discrimination

and Exploitation

SOCIAL NETWORKS

SOCIALSAFETY

NET

SafeAffordable

Housing

SocialConnection

& Safety

QualityEducation

Job Security

LivingWage

Transportation Availabilityof Food

Psychosocial Stress / Unhealthy Behaviors

Adapted from R. Hofrichter, Tackling Health Inequities Through Public Health Practice.

Segregationists Assimilationists Anti-Racists

Deploy specific strategies to address the multiple determinants

of health on which health care organizations can have a direct

impact

Decrease institutional racism within the organization

Make health equity a strategic priority

Develop structure & processes to support health equity work

• Demonstrate leadership commitment to improving equity at all levels of the organization

• Secure sustainable funding through new payment models

• Establish a governance committee to oversee and manage equity work across the organization

• Dedicate resources in the budget to support equity work

• Health care services (CLAS, CHW, co-design processes)• Socioeconomic status (fair pay & opportunity for

employees)• Physical environment• Healthy behaviors

• Physical space: Buildings & design• Health insurance plans accepted by the organization• Reduce implicit bias within organization policies, structures

& in patient care

• Leverage community assets to work together on community issues related to improving health & equity

IHI (Institute for Healthcare Improvement) Framework To Achieve Health Equity

1.

2.

3.

4.

5.

Wyatt R., Laderman M., Botwinick L., Mate K., Wittington J. Achieving Health Equity: A Guide for Health Care Organizations. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2016. (Available at ihi.org)

Develop partnerships with community organizations

Root cause analysis

Some of the underlying reasons for lack of effectiveness of RCAs in improving patient safety include the lack of standardized and explicit processes and techniques to:

• Identify hazards and vulnerabilities that impact patient safety and then prioritize them to determine if action is required

• Identify systems-based corrective actions• Ensure the timely execution of an RCA and formulation of effective

sustainable improvements and corrective actions Ensure follow-through to implement recommendations

• Measure whether corrective actions were successful• Ensure that leadership at all levels of the organization participate in

making certain that RCAs are performed when appropriate, in a timely manner, and that corrective actions are implemented to improve patient safety

Rules to 5 whys

Rule 1. Clearly show the “cause and effect” relationship.Rule 2. Use specific and accurate descriptors for what

occurred, rather than negative and vague words. Avoid negative descriptors such as: Poor; Inadequate; Wrong; Bad; Failed; Careless.

Rule 3. Human errors must have a preceding cause.Rule 4. Violations of procedure are not root causes, but must

have a preceding cause.Rule 5. Failure to act is only causal when there is a pre-

existing duty to act.

“5 Whys” Exercise

EVENT: What happened?

PATTERN: What’s been happening?

ACTION: What are the implications for action?


Phase 1: • Identified 3 clinical sites

• Assessed cultural competency of policies and procedures that impact maternal/infant health (pre-assessment)

• Met with sites to review assessment & talk about needs

• Drafted recommendations


Phase 2: • Reviewed recommendations (universal intake

process, earlier access to care, equity trainings, substance abuse trainings, HR practices)

• Implement recommendations (training evaluations)

• Plan to assess after 1 year (post-assessment consultant evaluation, summary/process report)

Current Work

• Phase 2: Early Access to Care• Updated and documented intake processes & workflow• Created reports with entrance to care data• Updated intake process for first prenatal visit• Working to create & implement unified SDOH

questionnaire • Offered trainings • Post Assessment and review in September

• Sustainability: • Processes and procedures incorporated into each clinic• Connecting with partner agencies for continued training

needs• Incorporate into internal QI processes

Successes & Challenges

Successes • Engagement from clinical

partners• Unified approach to SDOH

across Kalamazoo• Changing culture around

access to care• Support for early access to

care • Median first prenatal visit now

occurring in first trimester

• Interest in trainings • 8 events completed• 2 planned

Challenges• Securing an external

consultant

• Consistent follow-up with multi-sector partners

Best Practices

HRSA MCH CoIINAssociation of Maternal & Child Health Programs (AMCHP)FL, IL, KY, MA, NC, NM, NV, OH, OR, RI, SC, TX, WISocial determinants of health

National Institute for Children’s Health Quality (NICHQ)AR, MS, NY, TNSudden Unexpected Infant Death

Project Concern International (PCI)CoIIN Team States: AZ, CA, NM, TXEarly prenatal care & social determinants of health

University of North Carolina - Chapel HillCA, DE, NC, OKPreconception health

AMCHP Innovation Station

Data as a Health Justice StrategyCathy Kothari PhD (Assoc Prof, WMed & Cradle Epi)

COMMUNITY-BASED, POPULATION HEALTH

RESEARCH

CRADLE-KALAMAZOO DATA BACKBONE

CQI – FIMR

CARE COORDINATION REGISTRY

COMMUNITY-BASED POPULATION HEALTH

RESEARCH

0.0%

10.0%

20.0%

7.7%

10.9%

$ $$$

11.3%

4.3%White Infants

13.0

3.6

Black Infants

*3-year moving average, 2014-2016, Kalamazoo County

3.6 Relative Rate

DISPARITY

Infants of Color have Worse Birth OutcomesLaser on Equity

Infant Mortality RateKalamazoo County, 2010-2017 estimate

Parsing Root Causes: Poverty

Infant Mortality RateKalamazoo County, 2010-2017 estimate

Poverty Risk Not Distributed Equally

Infants of Color

…Regardless of IncomeInfant Mortality Rate

Kalamazoo County, 2010-2017 estimate

Parsing Root Causes: Structural Racism

Race

Structural Discrimination(SES)

Moms Health Experiences Survey Study-Recruited women from postpartum floor-Recruited 10% of county maternal population-Phone survey, 2 months postpartum-Neighborhood & Personal SDOH

30.1%

70.2%

% Exposed to Poverty (N=240)

Women of color(n=94)

White women(n=146) * p<.001

Parsing Root Causes: Poverty

Poverty is deeper among women of color• more likely to be going

hungry• without transportation

Isolated• without a support network• or a network that is just as

deprived

Parsing Root Causes: Segregation

Segregated into poverty-Concentrated poverty in 100% higher density Black neighborhoods(11 of 11 census tracts)

VS

-Concentrated poverty in 21.1% of higher density White neighborhoods(8 of 38 census tracts)

Parsing Root Causes: Interpersonal Racism

Race

Interpersonal Discrimination(EoD scale)

Structural Discrimination(SES)

Experiences of Discrimination Scale*1. How often are you treated with less courtesy or respect2. How often do you receive poorer service than other people3. How often do people act as if they think you are not smart4. How often do people act as if they are afraid of you5. How often are you followed around in stores6. How often are you threatened or harassed

*Discrimination Index: Almost every day, At least once a week, A few times a month, A few times a year, About once a year, Never0 to 30, higher indicates greater discrimination

White26.0%12.3%16.0%9.6%4.1%1.4%

Of Color43.6%22.3%28.7%16.1%16.0%3.2%

% Monthly

* p<.001

Parsing Root Causes: Interpersonal Racism

Interpersonal Discrimination(EoD scale)

Everyday Discrimination Scale (Williams, 2012)

CQI – FIMR

Cradle-Kalamazoo Fetal Infant Mortality Review (FIMR)(mid-2015 through mid-2018)

FIMR: The Process

DEATH NOTIFICATION & MONITORING

ABSTRACT RECORDS

INTERVIEW FAMILY

CASE SUMMARY

MULTI-DISCIPL. REVIEW

IDENTIFY SYSTEM GAP(S)

RECOMMENDATIONS

POLICY STATE ADVISORY COUNCIL

COMMUNITY ACTION TEAM

NATIONAL FIMR

1. SURVEILLANCE

2. REVIEW

3. ROOT CAUSE

4. PREVENTIVE ACTION

Core Team:-co-leads-abstractors-family interviewers-coordinator-MPH, MSW interns

Review Team:-42 members-15 organizations:

-Medical-Public health-Social service-Criminal justice-Education-Behavioral health

Accomplishments:• Held 34 monthly meetings• Reviewed 56 cases of infant / stillbirth death

• 76% with interviews (in last year)• Identified multiple social / health system gaps • Recommendations to Cradle Steering Team (CAT)

• Created process for submitting recommendations to the state

• Helped conduct state training

• Presenting at national medical QI conference• National Workgroups on Disparities• Mentor site, Nat’l Ctr Fatality Review & Prevention

FIMR: The Accomplishments

CARE COORDINATION REGISTRY

OBJECTIVES– Facilitate access:

• Home Visitation referral portal for agencies, clinics, & community

• Gryphon Place 2-1-1 Hotline

– Frontline support:• Updated contact info for retention• Close the loop on open referrals

through case sharing

– System-level CQI, continuum of care

– Accountability, health disparity outcomes

Coordinating Resources: Data Backbone

CARE COORDINATION REGISTRY: Expanding the Registry

EXPANSIONScompleted…1. Agency-based CHW pilot

exports / referrals

in process…2. Community self-referrals

funded, planned….3. Street-reach CHW

exports/referrals4. Interconceptional women,

infants, fathers5. Clinic, office referrals6. EHR- birth / death exports

Coordinating Resources: Process Metrics

nrllen

67

PREGNANT POPULATION:

7,095 women

3,725 women

INCOMING REFERRALS*

(1,916 Women)

* Prenatal referrals in during 29-month period: January 1, 2016 through April 15, 2018

ENROLLED**(654 WOMEN)

** Enrolled up through June 15, 2018

Race Women% of

Referred% of

Popul.Non 636 55.8 % 23.4%

White 504 44.2 % 76.6%(blank) 776

SESMedicaid 1075 97.0 % 43.5 %Private 33 3.0 % 56.6 %(blank) 808PPBO

Yes 121 11.0% 6.5 %No 982 89.0 % 93.5 %

(blank) 813

Race WomenEnrollment

RateNon 337 53.0%

White 225 44.6 %(blank) 92

SESMedicaid 527 49.0 %Private 20 60.6 %(blank) 107PPBO

Yes 56 46.3 %No 558 56.8 %

(blank) 648

CARE COORDINATION REGISTRY: System-level CQI(2016 through mid-2018)

68

Measuring Impact: Outcomes

69


70


Thank You!!Funding: 71

Cradle Kalamazoo - Collective Impact in Action

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